Montebello Assisted Living 4 LLC

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of four personnel reviewed. The deficient practice posed a potential TB exposure risk to residents and the required information could not be verified. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E3's and E5's personnel records revealed both caregivers were hired on November 10, 2024. 4. A review of E3's personnel record revealed a negative TB skin test that was less than 12 months old, however, no additional documentation of freedom from infectious TB was available for review, or documentation for assessing risk of prior exposure to infectious tuberculosis. Based on E3's hire date, this documentation was required. 5. A review of E5's personnel record revealed a negative TB skin test that was less than 12 months old, however, no additional documentation of freedom from infectious TB was available for review, or documentation for assessing risk of prior exposure to infectious tuberculosis. Based on E5's hire date, this documentation was required. 6. In an interview, E2 acknowledged E3 and E5 did not provide documentation of freedom from infectious TB as specified in R9-10-113. 7. Technical assistance was provided on this Rule during the inspection conducted on March 6, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for one of three residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual … is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R2's medical record revealed a chest x-ray. However, documentation was not available indicating R2 had a previous positive TB skin test or blood test, and without such documentation, a chest x-ray is not acceptable as documentation of freedom from TB. No additional documentation of freedom from infectious TB was available for review. Based on R2's acceptance date, this documentation was required. 3. In an interview, E2 acknowledged R2 did not provide current documentation of freedom from infectious TB, as specified in R9-10-113. 4. Technical assistance was provided on this rule during the inspection conducted on March 6, 2023.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident, for one of three residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a service plan dated February 20, 2025. The service plan stated, "[R2] was Bedbound/ Wheelchair bound. [R2] is a two person assist with the use of a mechanical lift for transfers. [R2] Full assist." However, there was no documentation of the need for repositioning. 2. In an interview, E2 reported the staff repositioned R2 every 3 hours and as needed. E2 acknowledged R2's written service plan did not include the amount, type, and frequency of the services being provided to R2.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed multiple ambulatory residents. 3. During the environmental tour, the Compliance Officer observed the front door leading to the front yard. The door leading out to the front yard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the door was not controlled and the door chime was turned off. 4. During the environmental tour, the Compliance Officer observed the door leading to the backyard. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the door was not controlled and the door chime was turned off. 5. During the environmental tour, the Compliance Officer observed a door leading to the backyard from R2’s room. The door leading out to the backyard from the facility did not control or alert employees to the egress of a resident to the outside area. 6. In an interview, E2 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on documentation review, observation, and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed multiple ambulatory residents. 3. During the environmental tour with E2, the compliance officer observed the following; - Multiple tripping hazards in the form of extension cords strewn across the floor in the living room area. - In the backyard, two garden hoses were found lying unsecured across the walking path. - A wheelbarrow containing multiple garden tools, including rakes and shovels, was left unattended in an accessible outdoor area. - The back gate leading out of the facility was also found to be unlocked. 3. In an interview, E2 acknowledged the facility was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on documentation review, observation, and interview, the manager failed to ensure the swimming pool on the premises of the assisted living facility was enclosed by a wall or fence with a self-closing, self-latching gate that was locked when the swimming pool was not in use. The deficient practice posed a risk to the physical health and safety of residents with access to the swimming pool. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed multiple ambulatory residents in the facility. 3. During the environmental tour with E2, the Compliance Officer observed a swimming pool on the premises, however, the pool gate was unlocked. The pool was found uncovered and empty. 4. In an interview, E1 acknowledged the swimming pool gate was unlocked.